Pain Management of Refractory Hidradenitis Suppurativa: Case Report

Background: Hidradenitis suppurativa (HS) is a chronic, relapsing, and painful inflammatory condition of the skin. Pain in HS is one of the most common symptoms and has a devastating effect on quality of life. Here, we present a unique case of a patient with HS and pain management guidelines used to treat her condition.  Case Report: This is a 42-year-old woman with a history of HS, hypertension, depression who presented with one month of pain in her groin crease, vulva, and rectum. She was recently discharged from the hospital for HS superinfection. She was treated with intravenous and oral antibiotics. She previously tried treatment with acetaminophen, lidocaine 2% jelly, gabapentin 400 mg TID, oxycodone, dilaudid, adalimumab, infliximab, topical clindamycin, intralesional steroid injections, and doxycycline. The pain management specialist recommended continuing treatment with gabapentin 400 mg TID and titrate to 600 mg TID as tolerated, and to follow up with the dermatology team to restart infliximab. Discussion: This case demonstrates a complicated, refractory HS condition that necessitates first, second, and third line treatment modalities. Pain control in HS starts by having best control of the underlying disease. The United States and Canadian Hidradenitis Suppurativa Foundations clinical guidelines suggest acute pain management should include topical analgesics (ie, lidocaine), oral acetaminophen, and oral nonsteroidal anti-inflammatory drugs. Chronic pain management should focus on a multidisciplinary approach. Clinical guidelines recommend escalating oral analgesics for pain that doesn’t respond to first-line agents. Opiate use should follow the World Health Organization pain ladder of tramadol, codeine, hydrocodone, and morphine. Neuropathic pain can be treated with pregabalin or gabapentin, titrated as tolerated by patients. Chronic HS lesions can be treated with wide local scalpel, CO2, or electrosurgical excision, and recurrent nodules can be deroofed or excised. Superior hypogastric plexus block and/or ganglion impar block can be considered for refractory cases. Conclusion: HS is an extremely painful condition severely affecting quality of life. Adequate pain management is vital, and a stepwise approach is recommended.